PROPERTY CLAIM FORM

Date:	Date Lodged:
Contact Name:	Claim No:
Phone:	Claim Manager:
Mobile:	Phone No:
Email:	Assessor Details:

Insured:
Underwriter:	Excess:
Policy Type:	Policy No:
Registered for GST: Yes / No	Amount: %
ABN:

Type of Claim:
Date of the Incident:	Time:
Location:
How did the incident happen:

Other details:
Where the police called: Yes / No	Attending Officer:
Incident No:	Police Station:
Third Party details:

Repairers name:
Phone number:	Do you have a quote|tax inv: Yes / No
Email:	Do you have images: Yes / No / NA
Other details:

Comments:
$
$
$
Less GST	$
Less Excess	$
Claim Total	$